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ChronicPancreatitis
AraSahakian,M.D.AssistantProfessorofMedicine
USCcorelecture
WhatisChronicPancreatitis
• Progressiveinflammatorydisease• Pancreaticparenchymareplacedw/fibroustissue
• Destructionofacinarandisletcells.• Painandlossoffunction(exoandendo)• Diseaseofmorbidity(notmortality)
Pathogenesis
• Usuallyhistoryofacutepancreatitis• Riskofprogressiongreatestwithsmoking/etoh• Mostwithacutepancdon’tdevelopchronicpanc
• 2-hithypothesis– Acutepancingeneticallysusceptiblept,enhancedbyenvironmentalfactors• PRSS1,SPINK1,CFTR• ETOHandsmoking
Presentation
• Chronicupperabdominalpain– Worsewitheating
• Crosssectionalimagingcanbenormal(early)• Endocrine/exocrineinsufficiencyandchangesinimaging(late)
• Phenotypesofchronicpanc– Cysticfibrosis:exocrineinsuffw/opain– Chroniccalcificpancinptw/ETOH
Diagnosis
• Histology:Goldstandard,Limitations– Patchydisease– Falsepositivesinelderly,smokers,etoh– Riskofpancreatitiswithbx– Notfrequentlyused
Diagnosis
• Functionaltests– Secretinstimulation(HCO3)– Fecalelastase– Serumtrypsin– CCKstim:looksatlipaseconcentrationinduodfluid
Diagnosis
• Imagingtests– KUB
• Costeffective(cheap):Lowsensitivity,highspecificity– MRCP=EUS=ERCPforsensitivity
• ERCPnotindicatedfordiagnostic• CTgoodforseeingcalcifications
EUSfindings
• Rosemontcriteria– Hyperechoicfoci,stranding,lobularity– Dilatedduct,stones,hyperechoicductmargins
AfterESWLBeforeESWL
Treatment
• Analgesics/Narcotics• Enzymes• NerveBlocks• Endoscopictherapy(targeted)• Surgicaltherapy
Treatment
• Cochranereview:2009.10Trials.Pancreaticenzymeshavenobenefitinpainfromchronicpancreatitis.
Shafiqetal.CochraneDatabaseSystRev2009
EndoscopicTherapy
• EUSguidedceliacnerveblock– 50%havepainrelief,lastsfewweeks(notroutinelyrecommended)
• Pancreaticstoneextraction– ESWLforstoneextraction
• Pancreaticstricturetherapy• Ductaldisruptiontherapy(oftenrequiresurgery)• Pseudocystdrainage• Biliarystricturetherapy
Surgicaloptions
• Drainage(Peustow-pancreaticojejunostomy)–duct>5mm(>10mm)
• Resection(Whipple,distalpancreatectomy)• Totalpancreaticresectionwautoisletcelltransplantation
• Denervation-thoracoscopicsplanchnicectomy
Endoscopicvs.Surgicaldrainage• CahenNEJM2007• Randomizedprospective• 19endoscopic;20pancreaticojejunostomy• 24monthsoffollowup• Surgicaltherapydecreasedpaincomparedtoendoscopictherapy(75%v32%wpainrelief)
• Limitations:– Painreliefunexpectantlylowinendogroup(32%)– Majorcomplicationratehigherinthesurgicalgroup– Lowrateofendotechnicalsuccess(50%)
Therapy
• Endoscopictherapymaybeconsideredafirst-lineapproachforpain(pancreaticstones/strictures)
• MostDEFINITIVEtherapyisconsideredsurgery
• Peudocysts– Transpapillarydrainage• Pancreaticstenttobridgetheleak• SmallercystscommunicatingwithPD
– EUSguideddrainage• NolongerdonewithoutEUS
– Visualizevesselsanddebris• Throughstomachorduodenumintocystcavity• Increasinglywithlumenopposingstents(littledata)
Pain
• Painwasthoughttobeduetoductalobstruction– Treatmentwasaimedtorelievingobstruction(ERCP,surgery)
– Resultsunpredictable• Neurogenicpainandhyperalgesia– Painmedications(opioids,neuropathicagents)
• Slowprogression– ETOHandsmokingabstinence
• 40yearoldmalewithhistoryofETOHabusewhopresentswithseverechronicepigastricpain.Imagingdemonstratespancreaticcalcificationsandhoneycombing.Thepancreaticductis4mminsize.Noothercauseforhispainhasbeenfound.Whichfirstlinetherapyismostlikelytogivepainrelief
A) PregabalinB) PancreaticenzymesC) AmitriptylineD) Surgicalpancreaticojejunostomy(Peustow)
• 40yearoldmalewithhistoryofETOHabusewhopresentswithseverechronicepigastricpain.Imagingdemonstratespancreaticcalcificationsandhoneycombing.Thepancreaticductis4mminsize.Noothercauseforhispainhasbeenfound.Whichfirstlinetherapyismostlikelytogivepainrelief
A) PregabalinB) PancreaticenzymesC) AmitriptylineD) Surgicalpancreaticojejunostomy(Peustow)
• Pregabalin• RCTof64ptswithchronicpancreatitis• 300mgbidx3wks• Reducedpaincomparedtoplacebo(36%v.24%)P:0.02
• Opioiddoseswerereduced• Likelyaffectscentralsensitization
OlesunSS.Gastro2011
• 28yofemalewithepigastricpainworsewithmeals.Nowtloss,nodiarrhea.EGD,ultrasound,andCTabdarenormal.Sheisreferredtoruleoutchronicpancreatitis.NoFHofpancreaticdisease.NohxofETOH.Whichistrue?
A) IfsecretinstimshowshighHCO3secretion,thenshehaschronicpancreatitis
B) KUBwouldbesensitiveandspecificfordiagnosisC) ERCPshouldbeperformedD) MRCPissuperiortoEUSforearlydiagnosisofchronicpancE) GenetictestingforPRSS1(hereditarypancreatitis)should
notbeperformed
• 28yofemalewithepigastricpainworsewithmeals.Nowtloss,nodiarrhea.EGD,ultrasound,andCTabdarenormal.Sheisreferredtoruleoutchronicpancreatitis.NoFHofpancreaticdisease.NohxofETOH.Whichistrue?
A) IfsecretinstimshowshighHCO3secretion,thenshehaschronicpancreatitis
B) KUBwouldbesensitiveandspecificfordiagnosisC) ERCPshouldbeperformedD) MRCPissuperiortoEUSforearlydiagnosisofchronicpancE) GenetictestingforPRSS1(hereditarypancreatitis)should
notbeperformed
• 55yomalewithhxofETOHwith6monthsofepigastricabdominalpain,nausea,wtlossof15lbsover3months.Havingloosestools3-4x/day.RecentdxofDM.Amylase190;lipase66.CBC,chem12normal.Bestnextstep?
A)StoolanalysisB)CTabdomenC)FecalelastaseD)SerumtrypsinogenE)ERCP
• 55yomalewithhxofETOHwith6monthsofepigastricabdominalpain,nausea,wtlossof15lbsover3months.Havingloosestools3-4x/day.RecentdxofDM.Amylase190;lipase66.CBC,chem12normal.Bestnextstep?
A)StoolanalysisB)CTabdomenC)FecalelastaseD)SerumtrypsinogenE)ERCP
• CTscanshowsdilatedpancreaticductwithobstructingstoneintheheadofthepanc.Whatisthenextbeststepintreatinghispain?
A)EUSceliacblockB)CTceliacblockC)ERCPD)FentanylpatchE)Distalpancreatectomy
• CTscanshowsdilatedpancreaticductwithobstructingstoneintheheadofthepanc.Whatisthenextbeststepintreatinghispain?
A)EUSceliacblockB)CTceliacblockC)ERCPD)FentanylpatchE)Distalpancreatectomy
• CTscanshowsadilatedpancreaticductwithmultiplelargestonesinthebody/tailofthepancreasupstreamofastricture.Whatisthemostdefinitivewaytotreathispain?
A)ERCPwithESWLB)Pancreaticojejunostomy(puestow)C)OpioidsD)Pregabalin
• CTscanshowsadilatedpancreaticductwithmultiplelargestonesinthebody/tailofthepancreasupstreamofastricture.Whatisthemostdefinitivewaytotreathispain?
A)ERCPwithESWLB)Pancreaticojejunostomy(puestow)C)OpioidsD)Pregabalin
• 56yofemalewithchronicpancreatitisundergoingCTscanforworseningpain.Shehaslost15lbsinthepastfewmonths.
• Whatisthebestwaytomanagethenewpaininthispt?
A)Endoscopicdrainage(cystgastrostomy)B)PancreaticenzymesC)AntioxidanttherapyD)SurgicaldrainageE)Pregabalin
• Whatisthebestwaytomanagethenewpaininthispt?
A)Endoscopicdrainage(cystgastrostomy)B)PancreaticenzymesC)AntioxidanttherapyD)SurgicaldrainageE)Pregabalin